Don't Pay or Contract in Advance for
Chiropractic
Visits
at a "Discount" Price

Stephen Barrett, M.D.

Many chiropractors offer contracts under which patients pay in advance or agree to pay for many visits at a "discount" price. I have seen contracts for as many as 100 visits. Chiropractors who offer them typically tell all patients that long-term care is needed to prevent recurrence, spinal degeneration, or various serious viseases. Some chiropractors display a chart of "subluxation degeneration" or "spinal decay" that they say is inevitable without intensive and/or long-term care. All such advice represents overselling. Even if chiropractic treatment can legitimately help a problem, it is not possible to know in advance that a large specified number of visits will be needed.

In addition to excessive visits, contracts often contain provisions intended to discourage quitting. Some say that if treatment is stopped before all of the visits are used, the discount will be cancelled and visits used will be figured at their "full" price. Some contracts also call for an "administrative fee" for early stoppage.

Payment Arrangements

Three types of payment arrangements are common:

Installment payments to the chiropractor

Advance patient to the chiropractor

Use of a "health care credit card" in which the chiropractor gets paid by a loan company and the patient is obliged to repay the loan company

Installment payments pose the least risk because patients who stop "early" are unlikely to be forced to pay for more services than they have received. The amount of money is usually too small to make a lawsuit practical, and failure to pay medical bills will not affect a person's credit rating. Full advance payment is more risky because if the chiropractor refuses to make an appropriate refund for unused services, it may be difficult to obtain one. Third-party financing through a credit agency is very dangerous because no matter what happens between the patient and the chiropractor, the patient remains legally bound to repay the loan and failure to repay can seriously damage a person's credit rating.

Many chiropractors encourage patients to finance the contracted amount through CareCredit, a company that pays the chiropractor (minus a small fee) upfront and then collects from the patients. The process is typically described as an interest-free loan or interest-free credit plan. However, if payments are late, the interest and other fees can be very high. Some patients are led to believe that the chiropractor was simply extending credit with a payment plan. However, the CareCredit plan is a "non-recourse" loan from what the law would regard as an independent loan company [1].

The worst contract I have seen included a provision that the patient is responsible for any legal fees incurred by chiropractor for
collection of any unpaid balances. That means they wind up in court and the patient loses, the patient could be faced with a large legal bill.

Contract-Related Legal and Regulatory Actions

In 2008, in response to complaints from patients, the Maryland Board of Chiropractic and Massage Therapy Examiners advised chiropractors not to use "extended treatment contracts":

A licensee is free to use whatever patient contract he/she desires provided that the contract is clear, fair, and may be terminated at any time for any reason, without penalty by the patient. If a contract unduly restricts a patient to commit for extended periods of treatment requiring penalties for termination, the contract is unconscionable and considered as unprofessional conduct by the Board. Licensees must carefully assess binding a patient to an extended care contract since parameters of care, patient health and patient desires change as time goes by. For example, a patient may simply not like the personality or treatment methods of the licensee. In such cases, the patient must have the free,
unfettered and unobstructed right to terminate the patient care contract for any reason and at any time without penalty. The Board has received numerous complaints from patients regarding the unfair use of such contracts. For these reasons, the Board strongly advises licensees to refrain from the use of long-term, extended treatment contracts.

During the same year, the Maryland Board issued a consent order that placed Andrew Joyce, D.C. on probation for three years, fined him $9,000, and required that his practice be monitored. The order described how Joyce had contracted to provide long courses of treatment but failed to adequately document the need for the treatment, what took place during many of the visits, the patient's status at each visit, and what treatments were administered during each visit. The board also found many improprieties in Joyce's insurance billings [2].

In 2007, the Kansas State Board of Healing Arts charged Bradley Eck, D.C., of Wichita, Kansas, with unprofessional conduct. The complaint stated that he engaged in deceptive advertising and used improper contracts under which patients paid "discount" prices in advance for multiple visits but would receive no refund for visits that were not used [3]. In February 2009, the case was settled with a consent order under which Eck must pay investigative costs plus a $5,000 fine; serve probation for two years; and provide full refunds to patients listed in the complaint who did not receive all of the treatments for which they contracted [4].

That same month, a small claims court judge voided the contracts between chiropractor Donald Harte and two former patients who sued Harte in Marin County, California. Gertrude West, a retired attorney, had sought help for knee pain but was advised to have intensive care for “subluxation degeneration” of her spine. She contracted for 100 visits with a discount for advance payment but severe penalties for discontinuing. After 49 visits over a 4-month period, she concluded that she was not being helped and asked that payment for the unused visits be refunded. When Harte refused, she filed suit. The judge concluded that (a) West had been misled, (b) the penalty clause was "unconscionable,"
and (c) West was entitled to a $6,401 refund, plus the cost of the suit [5]. The other former patient, Victoria Pollock-Grasso of Tiburon, objected to Harte charging a $559 "administrative fee" when she decided to stop seeing him. Grasso said she stopped because an orthopedist she consulted for a second opinion said she had degenerative disc disease in her cervical spine and that Harte's manipulation of her neck could cause her to have a stroke [6]. Harte appealed the West ruling, asserting that the contract was enforceable and that he was entitled to reasonable compensation for services rendered. The small claims appeal judge reduced the award to $4,589.00 plus costs of $75.00. The judge did not explain how he decided what was "reasonable," but he clearly agreed that the contract was not.

Documents from the case show how Harte used scare tactics. His "report of findings" is a pre-printed form with fill-in sections such as:

"Dysautonomia: mild | moderate | severe | very severe." In this area Harte checked "severe" and penned in the words "May get worse."

"Diseases you have, apparent or not , diseases that are in the process of developing, and every aspect of your . . . body function that is operating at less than optimal level. Unknown diseases?

"Pathological changes in the spine itself, from years of VSC: Subluxation Degeneration."

The bottom of the form contains "recommendations for initial intensive care," with blanks to fill in the number of visits per week, and a statement that the speed and degree of eventual recovery are influenced by consistency in following the recommendations. The contract called for 92 regular visits at $97 each ($55 Medicare discount price) and 8 "progressive examination visits" @ $250 each—said to be a total value of $7,080 for a discount price of $6,354 if paid in advance. It goes on to say, however, that if care is stopped before completion, services will be charged at regular prices and a 10% "administrative fee" would be added.

In 2009, the Minnesota Attorney General and Minnesota Board of Chiropractic Examiners filed a lawsuit accusing Express Health of Lakeville, Minnesota and its owner Cory Couillard, D.C. of engaging in predatory lending practices [7,8]. The suit alleged:

The sales process often began with free health or spinal screening at a public location where it was recommended that they undergo a "full" office evaluation.

After the full evaluation, patients were typically told that without extensive treatment, they were headed for serious health problems.

Couillard and his clinic aggressively enrolled patients in the CareCredit Credit Card offered by GE Money Bank, convincing some patients to complete applications by telling them that they were not applying for a credit card but that the clinic simply wanted to check to see if they would qualify for credit.

Unbeknownst to these patients, Express Health and Couillard then submitted the application to the Bank, which issued a CareCredit credit card in the patient's name. In order to ensure that patients qualified for a credit card, the defendants sometimes submitted to the lender false annual income for patients, in some cases doubling or more patients' actual income.

Once patients were issued a credit card, the defendants placed lump-sum charges of up to $5,040 on the credit card, without patients' knowledge or consent.

In the two-year, five-month period between December, 2006 and April, 2009, the clinic charged $560,850 to CareCredit credit cards issued to its patients. About half that amount was later refunded by the clinic to patients who complained.

The Attorney General's office also published a Consumer Alert cautioning patients to be wary of high-pressure sales pitches using health care credit cards [9]. After the lawsuit was settled, the Minnesota licensing board suspended Couillard's license [10].

In 2011, the Minnesota Board suspended the license of Jeffrey Styba, D.C. for improperly enrolling patients into credit card plans, overbilling them, ordering unnecessary services, and failing to keep adequate records. The board noted that when enrolling patients in a CareCredit plan, Styba or a staff member would complete the application form online and routinely claim an annual income at or above $120,000. Rather than inquiring about the patient's income, he or his staff would just "plug in a number." Styba was ordered to pay a $30,000 administrative fine and pass an examination in ethics and boundaries. When he did neither, the board extended his suspension and in 2014 canceled his license [11].

The South Dakota Board of Chiropractic Examiners has banned the use of prepayment contracts and taken disciplinary action against at least three chiropractors who used them:

In 2011, the board disciplined Josh Biberdorf, D.C. for entering into contracts in which patients received a discount for paying for services in advance. In South Dakota, entering into a contract that obligated patients to pay for future care is considered unprofessional conduct. The case was settled with a consent agreement under which Biberdorf was assessed $10,000 and placed on probation for one year during which the board was entitled to review his records to verify that he had discontinued the use of prepayment contracts. He was also required to complete the ProBE Ethics and Boundaries Program. [12]. During the proceedings, Biberdorf told the board that about 20% of his patients entered prepayment. In a subsequent newspaper interview, he said that although he did not contest the proceedings, he contended that prepayment contracts are ethical and were common among the state's 385 chiropractors. In the same article, the state board's attorney said that "prepaid plans may create, in the mind of the patient, a perceived need for care which may exceed appropriate care under the circumstances" and "may also create improper financial incentives for chiropractors to provide unnecessary treatment." [13] At the time he was disciplined, Biberdorf was president of the South Dakota Chiropractors Association.

In 2013, the board reprimanded Jayson D. Snyder, D.C. and placed him on probation for one year. He was also assessed $1,750 in costs, ordered to cancel all contracts that had been signed that year, and ordered to participate in the ProBE program [14].

In 2013, the board began a disciplinary action against Bryan Williams, D.C. for unprofessional conduct that included using prepayment contracts in violation of the board's rules. Although William denied the allegations, he told the board he was planning to relocate to another state and signed a consent agreement under which he agreed to pay administrative costs of $4,400. He also voluntarily surrendered his license but is permitted to reapply if he wants to practice again in South Dakota [15].

In 2013, the Texas Board of Chiropractic Examiners fined Randall Johns, D.C. $1,000 and ordered $590 restituition to a former patient who had paid $2,675 in advance but stopped before having all of the treatments, and was not reimbursed for the treatments not received [16].

A Florida law enacted in 2012 limits the amount that a chiropractor can hold in trust to $1,500. That should prevent Florida chiropractors from collecting full contract amounts in advance from patients who pay directly. However, contracts with installment plans can still be used [17]. That same year, David Yachter and the Florida Board of Chiropractic Medicine signed a settlement agreement under which he was reprimanded, ordered to pay a $6,000 fine plus $5233.31 for costs, placed on probation for 2 years, and required to take continuing education courses in risk management, record-keeping, and coding [18]. The agreement settled charges that (a) he had improperly recomended that an 87-year-old patient undergo treatment that included 80 spinal adjustments, (b) the patient paid $3,034.50 in advance to get a discounted price and (c) Yachter had failed to follow proper trust accounting procedures for the payment [19].

Michael McClain, D.C., who operates Vital Energy Chiropractic in Helena, Montana has been disciplined by the Montana Board of Chiropractors for marketing treatment plans with 72 or 80 prepaid visits. In 2013 and 2014, he settled complaints by revising his procedures to separate recommendations for "medically necessary/corrective care" from those for "wellness/maintenance care." He is also required to administer an informed consent form that specifies that his wellness/maintenance plan "makes no representation that any treatment it offers will cure or prevent any condition, disease, or event, other than vertebral subluxation." [20] In 2014, the Montana board also reprimanded his wife, Terah McClain, D.C., for her involvement with one of the patients [21].

Government Actions Involving CareCredit

In 2013, the Financial Protection Bureau ordered GE Capital Retail Bank and its subsidiary, CareCredit to refund up to $34.1 million to potentially more than 1 million consumers who had been victims of deceptive credit card enrollment tactics [22]. The agency's press release noted that at professional offices around the country, consumers were signed up for CareCredit credit cards they thought were interest free, but were actually accruing interest that would kick in if the full balance were not paid at the end of a "promotional" period. The settlement also called for better disclosures [23]. Earlier that year, GE Capital Retail Bank and CareCredit settled a lawsuit by the New York Attorney General by agreeing to similar safeguards (plus a few others) and payment of $125,000 to cover the costs incurred during the investigation and monitoring of the matter [24]. The documents in these cases did not mention whether chiropractic offices were involved, but I assume they were.

My Advice to Consumers

The best way to avoid being tricked is to stay away from tricksters. In line with this, I have published a list of warning signs that are associated with overselling [25]. The most important are "free examinations" and recommendations to treat "subluxations." If you have signed a chiropractic contract of the type described above and later conclude that keep the following mind:

Contracts covering multiple visits over a period of months are probably not enforceable. Penalty causes are probably unenforceable, and most chiropractic licensing boards would view them as unethical. However, if a health care credit card is use to make payment, the patient is obligated to repay the loan company.

If you have had as much help as you need, don't let a contract intimidate you. Ask for cancellation of the contract and a full refund of unused services with no penalty.

If you conclude that the whole treatment plan was unnecessary, demand a refund of all payment.

Don't worry excessively about a threat to turn you over to a collection agency. Failure to pay chiropractic bills will not affect your credit rating. If an agency becomes involved, simply tell them to stop contacting you.

Be prepared to complain to the state chiropractic board and the Better Business Bureau. Before doing so, give the chiropractor a final chance to resolve the situation amicably.

If you plan to complain, get a copy of your records so they cannot be altered later.

A suit in small claims court might be successful. In some states, a suit under the state's Unfrair Trade Practices Act could lead to a significant penalty and reimbursement of attorney fees [26,27].